Healthcare Provider Details

I. General information

NPI: 1578702908
Provider Name (Legal Business Name): FAITH HARBOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 RICHPOND ROCKFIELD RD
BOWLING GREEN KY
42101-7408
US

IV. Provider business mailing address

1043 PEDIGO WAY STE 7
BOWLING GREEN KY
42103-7197
US

V. Phone/Fax

Practice location:
  • Phone: 270-366-6843
  • Fax: 270-842-6213
Mailing address:
  • Phone: 270-366-6843
  • Fax: 270-842-6213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ALICIA FAYE MURPHY
Title or Position: OWNER
Credential:
Phone: 270-366-6843